title: Expanding relevance of aortic valve repair-is earlier operation indicated?
abstract: OBJECTIVE
  To define the durability of aortic valve repair (AVRep) and the effect of surgical timing on late survival.
  
  
  METHODS
  From June 1986 to June 2011, 331 patients underwent elective AVRep for aortic regurgitation (mean age, 53 ± 17 years; 76% men). The repair methods included commissuroplasty (n = 270; 81%), triangular resection and plication (n = 106; 32%), resuspension or cusp shortening (n = 102; 31%), and perforation closure (n = 23; 7%).
  
  
  RESULTS
  In-hospital mortality was 0.6% (2 of 332). Four patients (1%) experienced early repair failure; two underwent repeat repair. Overall survival was 91% and 81% at 5 and 10 years, respectively. After adjusting for age, greater left ventricular end-systolic dimension (per 5 mm; hazard ratio [HR], 1.49; 95% confidence interval [CI], 1.23-1.79; P < .001) and lower ejection fraction (per 5%; HR, 1.42; 95% CI, 1.25-1.63; P ≤ .001) were significant predictors of long-term mortality. Patients with ejection fraction < 50% and left ventricular end-systolic dimension > 50 mm had significantly greater odds of late death (HR, 3.46; 95% CI, 2.05-5.82; P < .001 and HR, 2.08; 95% CI, 1.05-4.12; P = .036, respectively). The risk of aortic valve reoperation was 10% and 21% at 5 and 10 years, respectively. The presence of severe aortic regurgitation (HR, 2.2; 95% CI, 1.1-5.06; P = .02) and more than mild regurgitation at discharge (HR, 5.87; 95% CI, 2.67-12.68; P ≤ .0001) were predictors of late reoperation. Freedom from other valve-related events was 94% and 91% at 5 and 10 years, respectively. Forty-seven patients (21%) with intact valve repair were using warfarin at the last follow-up visit.
  
  
  CONCLUSIONS
  AVRep can be performed with excellent late survival and freedom from valve-related events. Awaiting the onset of ventricular dysfunction increases the risk of late mortality, warranting earlier consideration of AVRep for patients with suitable anatomy.
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minn.
authors.forename: Vikas
authors.initials: V
authors.lastname: Sharma
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minn. Electronic address: suri.rakesh@mayo.edu.
authors.forename: Rakesh M
authors.initials: RM
authors.lastname: Suri
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minn.
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Dearani
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minn.
authors.forename: Harold M
authors.initials: HM
authors.lastname: Burkhart
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minn.
authors.forename: Soon J
authors.initials: SJ
authors.lastname: Park
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minn.
authors.forename: Lyle D
authors.initials: LD
authors.lastname: Joyce
authors.affiliation: Department of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine, Rochester, Minn.
authors.forename: Zhuo
authors.initials: Z
authors.lastname: Li
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minn.
authors.forename: Hartzell V
authors.initials: HV
authors.lastname: Schaff
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use; D001021:Aortic Valve / Q000503:physiopathology / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D058385:Cardiac Valve Annuloplasty; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D018579:Patient Selection; D011183:Postoperative Complications / Q000401:mortality / Q000601:surgery; D016016:Proportional Hazards Models; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013318:Stroke Volume; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome; D016277:Ventricular Function, Left; D014859:Warfarin / Q000627:therapeutic use; D055815:Young Adult
chemical_list: D000925:Anticoagulants; D014859:Warfarin
keywords: 35; AR; AVR; AVR(ep); CI; EF; HR; LVESD; aortic regurgitation; aortic valve repair; aortic valve replacement; confidence interval; ejection fraction; hazard ratio; left ventricular end-systolic dimension